Provider Demographics
NPI:1700017498
Name:HENNESSEY, JENNIFER BROOKE (EDD, LPE, BCBA)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BROOKE
Last Name:HENNESSEY
Suffix:
Gender:F
Credentials:EDD, LPE, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 TROXELL LN
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-9311
Mailing Address - Country:US
Mailing Address - Phone:501-513-9007
Mailing Address - Fax:
Practice Address - Street 1:611 COURT ST STE 1
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-5417
Practice Address - Country:US
Practice Address - Phone:501-940-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
AR99-5E103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst